In the Headlines: Use Less Medicine

Just a quick post today, because I wasn’t meaning to write here today but these two headlines jumped out and screamed to be linked to.

First, there’s this one, from Reuters, an impressively lengthy article about cancer screening and the difficulty in conveying the message that more screening is not always better. Beginning with a recap of the 2009 recommendation by the US Preventive Services Task Force that women under 50 could skip routine mammograms (Dr. Ned Calonge, who presided over that Task Force, received two death threats), the article looks at where things are at now with regard to informing the public about the need to dial back on screening for some conditions.

I won’t summarize the entire article here because my daughter is going to wake up from her nap any minute and we have another headline to get to. But what’s interesting about this article — aside from it’s length, which really is impressive, considering the short shrift so often given to anything without the word “breakthrough” in it — is that it’s focused on a movement toward reducing the amount of health care we receive, specifically mammograms and PSA tests. It also shows how closely tied screening recommendations are to political issues.

Next up is this article from US News & World Report on new concerns that targeted radiation (also known as brachytherapy) is being overused. The article is based on a new study in the Dec 16 online issue of the Journal of the National Cancer Institute (which, by the way, is run independently of the National Cancer Institute) recognizing the dramatic increase in targeted radiation treatment for breast cancer. The main point of the article is that this treatment modality is being used on women who are considered unsuitable according to the latest guidelines from ASTRO (American Society for Radiation Oncology). Importantly, this increase in use was happening before ASTRO released its latest guidelines. But that doesn’t justify the use – in fact, it highlights a key issue in healthcare, especially cancer treatment, which is the integration of new treatments into care before there is concrete evidence of true benefit.

According to the JNCI study, among 138,815 U.S. women diagnosed with breast cancer from 2000 to 2007, about 2.6% received brachytherapy. Of this 2.6%, 29.6% were considered “cautionary” candidates for the treatment, and 36.2% were considered “unsuitable.” Again, these classifications are being made after the fact—there were no guidelines classifying women as cautionary, unsuitable, or suitable candidates for brachytherapy during the years from which the data were collected. But the point that targeted radiation may be overused (or, was overused in recent years) is clear regardless of the timings. There are more details in the news article and the published study.

And then there’s this press release from UCSF about widespread mammogram use detecting lower-risk breast cancer, based on this new study (PDF) in Breast Cancer Research and Treatment. The message and purpose of this particular study are a little confusing, but I think they are trying to show that screening can help separate high-risk and low-risk tumors, so that women with low-risk breast cancer do not receive unnecessary treatment. Here is the last paragraph of the study’s discussion section:

The observation that a substantial fraction of screen-detected cancers have low and ultralow risk is valuable information. These types of cancers may account for the cases that others consider ‘‘overdiagnosis’’ [24]. However, when we initiate screening, we do not know which women are likely to develop ultralow risk or IDLE tumors. We can, however, recognize that such tumors are commonly identified today, discuss this with our patients, and perform tests that elucidate the underlying biology of the tumors detected. We can use this information to guide treatment recommendations and as the basis for the development of clinical trials that test the safety of less aggressive treat- ments for patients with the lowest risk tumors.

So, two headlines and one sort-of newsy item focused on the idea of overdiagnosis and overtreatment. Because the usual mix of stories in any given day usually isn’t themed along those lines, I thought it was noteworthy to see two in a row.

But lest you think you have entered some kind of alternative medical universe, fear not! There’s also:this
(“…generating buzz about a potential breakthrough that could transform cancer treatment.”
and this
(Avastin for nasopharyngeal cancer?)
and this
(disputing the alleged risks of brachytherapy for breast cancer discussed at a recent presentation at the San Antonio Breast Cancer Symposium, having nothing to do with the JNCI study above)and this
(it may help you now, but it will hurt you later)

All right, I lied, not such a short post after all. Who knew the nap would be this long? Maybe I am the one in the alternative universe.

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